KAE Cubs Pediatrics Medical Release

KAE Cubs Pediatrics Medical Release

Authorize KAE Cubs Pediatrics to release or obtain your child's medical records. Please complete all required fields.
Name of Parent/Guardian
Records to be Released/Obtained (Check all that apply)

Other
If Other, please specify
Name of Facility or Physician
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Purpose of Disclosure
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Parent/Guardian (Printed)
I understand that this authorization is voluntary and that I may revoke it at any time by submitting a written request. I also understand that once the information is released, it may no longer be protected under HIPAA. Unless otherwise specified, this authorization will expire one year from the date of signature below.

By signing below, I authorize the release or receipt of the medical information selected above.
Signature of Parent/Guardian
Date (Signature)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: